Beauty Curves Spa Intake Form
Client Information
Name
*
First Name
Last Name
Age
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Surgery Information
Surgery Date:
*
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Month
-
Day
Year
Date
Surgeons Name:
*
Surgeons Phone Number:
*
What kind of surgery did you have?
*
Lipo 360, BBL, Tummy Tuck, Arm lipo, chin lipo, thigh lipo
How did you hear about us?
*
Health Data
Do you have any allergies?
*
If yes, please specify on the field above.
Are you currently taking any medications?
*
If yes, please specify on the field above.
Have you been recently hospitalized?
*
If yes, please specify on the field above.
Do you have any of the following conditions? Seroma, or fibrosis.
*
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
*
If yes, please specify on the field above.
Location of painful areas
*
Consent and Waiver
I, undersigned, agree with the following statements:
*
I authorize Beauty Curves Spa to perform the treatment or necessary massage for my post operative care treatments.
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the massage treatment.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I understand that in order for my appointment to be schedule i need to send a deposit of $25 for in office visit or a deposit of $50 for mobile visit. Deposit will be sent either through Cash app @beautycurvesspa or zelle to 713-257-4184.
I understand that if I am more than 15 minutes late or fail to provide a cancellation notice at least 12 hours in advance, i will lose my deposit.
I understand that Beauty Curves Spa cannot accept any refund request, all services (includes packages) purchased, booked or completed services are final and non-refundable. And i may be able to exchange for another service of equal or less value if requested to exchange before 24 Hours of booked appointment. Services cannot be refunded on because of concern or expected results.
I acknowledge that all information I provided in this form is true and accurate.
Other
Signature of the Client
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
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